<form action="{:url()}" method="post" class="form_single">
    <div class="box">
      <div class="box-body">
        <div class="row">
          <div class="col-md-6">
            <div class="form-group">
              <label>医院名称</label>
              <span>（医院名称）</span>
              <input class="form-control" name="name" placeholder="请输入医院名称" value="{$info['name']|default=''}" type="text">
            </div>
          </div>
            
          <div class="col-md-6">
            <div class="form-group">
              <label>医院编号</label>
              <span>（请填写医院编号）</span>
              <input class="form-control" name="id" placeholder="请输入医院编号" value="{$info['id']|default=''}" type="text">
            </div>
          </div>

          <div class="col-md-4">
            <div class="form-group">
              <label>医院地址</label>
              <span>（填写医院地址）</span>
              <input class="form-control" name="address" placeholder="请输入医院地址" value="{$info['address']|default=''}" type="text">
            </div>
          </div>
          
          <div class="col-md-4">
            <div class="form-group">
              <label>医院联系人</label>
              <span>（填写医院联系人姓名）</span>
              <input class="form-control" name="address" placeholder="请输入医院联系人姓名" value="{$info['leader_name']|default=''}" type="text">
            </div>
          </div> 

          <div class="col-md-4">
            <div class="form-group">
              <label>医院联系人身份证号</label>
              <span>（填写医院联系人身份证号）</span>
              <input class="form-control" name="address" placeholder="请输入医院联系人身份证号" value="{$info['leader_code']|default=''}" type="text">
            </div>
          </div>
            
          <div class="col-md-4">
            <div class="form-group">
                <label>联系电话</label>
                <span>（医院小屋科联系电话）</span>
                <input class="form-control" name="telphone" placeholder="请输入医院小屋科联系电话" value="{$info['telphone']|default=''}" type="text">
            </div>
          </div>
            
          <div class="col-md-4">
            <div class="form-group">
                 <label>医院级别</label>
                 <span class="">（请选择医院级别）</span>
                 <select name="level" class="form-control">
                  {volist name='level_list' id='vo' key='k'}
                  <option value="{$k-1}" {notempty name="info['level']"}{if condition="$info['level'] eq $k"} selected="selected" {/if}{/notempty} >{$vo}</option>
                  {/volist}
                </select>
              </div>
            </div>

          <div class="col-md-6">
            <div class="form-group">
                <label>医院所属行政区域</label>
                <span>（医院所属行政区域）</span>
            {assign name="province" value="$info['county_id']|default='0'" /}
            {assign name="city" value="$info['town_id']|default='0'" /}
            {assign name="county" value="$info['room_id']|default='0'" /}
            {:widget('region/index', ['province' => $province, 'city' =>$city,'county'=>'','name'=>'id'])}
            </div>
          </div>
            
              
          </div>
        </div>
        
      <div class="box-footer">
          
        <input type="hidden" name="id" value="{$info['id']|default='0'}"/>
        
        {include file="layout/edit_btn_group"/}
        
      </div>
        
      </div>

</form>